MEDICARE: 1405 S. MONROE STREET OPERATIONS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	BH1286	WA

General Provider Information

NPI Number	:	1811938400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1405 S. MONROE STREET OPERATIONS LLC

Provider Business Mailing Address
First Line	:	101 SUN AVE NE
Second Line	:	COMPLIANCE DEPARTMENT
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-4373
Country	:	US
Telephone Number	:	505-468-5604
Fax Number	:	505-468-4681

Provider Business Practice Location Address
First Line	:	1405 S MONROE ST
Second Line	:
City	:	MOSES LAKE
State	:	WA
Zip	:	98837-4628
Country	:	US
Telephone Number	:	509-765-2200
Fax Number	:	509-765-9622

Authorized Official
Title or Position	:	VP ASST SECRETARY
Name	:	MICHAEL T BERG
Credential	:
Telephone Number	:	505-468-4742

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	02/18/2020

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